Provider Demographics
NPI:1063844231
Name:MARKET STREET ASSISTED LIVING
Entity Type:Organization
Organization Name:MARKET STREET ASSISTED LIVING
Other - Org Name:THE INN AT GLENELLEN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:J
Authorized Official - Last Name:REESE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-726-5790
Mailing Address - Street 1:9661 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:NORTH LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:44452-8564
Mailing Address - Country:US
Mailing Address - Phone:330-549-9661
Mailing Address - Fax:
Practice Address - Street 1:9661 MARKET ST
Practice Address - Street 2:
Practice Address - City:NORTH LIMA
Practice Address - State:OH
Practice Address - Zip Code:44452-8564
Practice Address - Country:US
Practice Address - Phone:330-549-9661
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-30
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2254R310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0085821Medicaid